What’s the buzz: bee productsand their potential value in diabetic woundhealing.Authors:, Frances R. Henshaw1, Stephen M. Twigg1,2 Susan V. McLennan1,2
Abstract:Foot ulceration, secondary to diabetes, is the most common reason for lower limb amputation, accounting for 50-70% of non-traumaticlower limb amputations. Rather than progressing through the usual wound healing phases, diabetic wounds become ‘stuck’,predominantly in the inflammatory phase. Normal feedback mechanisms that conclude the inflammatory stage are short-circuited, andthe inflammatory response is upregulated and persistent. Chronic diabetic wounds always have a bacterial load, and the increasedtissue bacterial burden may impede healing. Since ancient times, bee-derived products have been used as medicines and as potentialwound healing therapies. Their anti-inflammatory and anti-bacterial properties have been widely reported. Honey, propolis, royal jelly,and bee venom have pre-clinical wound healing properties. This review seeks to examine factors that prevent diabetic wound healingand the potential of four bee products to promote diabetic human healing in these wounds. The indication for key clinical trials in thisexciting area of bee-derived products is also emphasized.
INTRODUCTIONFoot ulcers and infections cause major morbidity for individuals with diabetes mellitus. Recognized for some decades,wounds in diabetic patients are prone to abnormal healing.1 Presently, because of diabetes about one amputation occursglobally every 30 seconds. This results in over 2,500 lower limbs being lost per day.2 Diabetes is the leading cause of non-traumatic lower-extremity amputations in the United States (US).3 For individuals with diabetes, the lifetime probability ofdeveloping a diabetic foot ulcer (DFU) is estimated at 10 to 25% (Centers for Disease Control and Prevention, 2011). In thedeveloped world, for people with diabetes having a foot ulcer is a leading cause of hospitalizations and is a major, but oftenunrecognized cause of morbidity associated with diabetes. It leads to suffering and a reduced quality of life for patients.4
Studies by Cavanagh et al., have shown that the costs of treatment for the patient are considerable. For example, theaverage cost of treatment of a DFU is the equivalent of six days of average income in the US and 5.7 years of average
PollsHow Is My Site?
Good Excellent Bad Can Be Improved No Comments
Vote View Results
HOME ABOUT US ARCHIVES FOR AUTHORS SPONSORSHIP OPPs SPONSORS
annual income in India. Although these findings do not take cost-effectiveness into account, they highlight the dramaticeconomic burden of a DFU.5 Australian data from the 2000 Fremantle Diabetes Study shows that the average length ofhospital stay for a DFU admission was 31 days and the cost was $17,089 AUD.6 During the study period, this represented9.3% of the total cost of diabetic hospitalizations.
Many factors contribute to wound healing deficiencies in DFUs. These include: 1) a decrease or impairment of growth factorproduction or concentration7, 2) an imbalance between the accumulation of extra cellular matrix (ECM) components andtheir remodeling by matrix metallo-proteinases (MMPs)8, and 3) impairment of macrophage activation and angiogenesisand/or collagen synthesis, which consequently result in wounds that heal slowly and incompletely.9,10 Thus, both the ‘soil’(metabolic environment and wound bed status) and the ‘seed’ (cells involved in wound healing) appear to be impaired indiabetic wounds. Additionally, the presence or persistence of bacteria is associated with tissue destruction, and it is well-known to all who treat patients with DFUs that a high bacterial load may contribute to impaired wound healing.
The cornerstone of care in DFUs is based on a careful assessment of the nature of the foot ulcer. These include precipitatingand predisposing factors, and four treatment elements, which are debridement and dressings, pressure offloading, antibiotictherapy, and where indicated, revascularisation. It is the individualization of such treatments to a specific patient in abalanced manner across the multiple health care displines that is key in optimizing foot ulcer healing in diabetes.11
Podiatrists (the treating foot care physician), vascular and foot surgeons, nurses, and broader disciplines, such asmicrobiologists and radiologists, all need to work together to realize the gold standard in outcomes for ulcer healing and tominimize hospital admissions and amputations.
With good care from a multidisciplinary team most DFUs will heal. However, it is unfortunate that some diabetic wounds willnot. Currently, the most common therapies used for DFUs are debridement and topical dressings (i.e., foams, hydrogels,nano-crystalline sliver, povidone iodine), antibiotic therapy, revascularization, and pressure reduction using a total contactcast or other device rendered irremovable. Newer therapies such as topical negative pressure therapy and hyperbaricoxygen therapy12 are generally expensive and often lack in supporting evidence (such as autologous platelet transfer13).These factors have precluded such treatments from becoming a mainstay of DFU treatment.
To improve healing rates in recalcitrant diabetic wounds in a cost-effective manner, researchers are looking at inexpensiveand readily available natural products. The relative inexpense of developing existing natural products or ‘neutraceuticals’ intowound healing therapies is particularly attractive because these therapies generally have low side effects. Since ancienttimes bee-derived products have been used as medicines and wound healing therapies. Recently there has been a revival ofinterest in bee-derived products, but to date the collective role these products play in diabetic wound healing has not beenstudied. Bee, or ‘Apitherapy‘ products, are of particular interest as they have anti-bacterial and anti-inflammatory properties,are inexpensive, and are generally well tolerated. This review seeks to investigate the functional properties of major bee-derived products and their potential to heal wounds in the diabetic foot.
THE STUDYThe Normal Wound Healing ProcessNormal cutaneous wound healing is the intricate process of the skin repairing itself following an injury. This process is highlyorganized and occurs as a series of well-ordered, overlapping events: haemostasis, inflammation, proliferation, andremodelling. Healing in the skin (Figure 1), and the approximate phase where delay in DFU healing occurs, is indicated bythe asterisk (*). Wound healing is a multicellular process that is completed with both barrier restoration and functionalrecovery of skin strength.14 At the cellular level, it involves multiple cell types with varying concentrations of cytokines,growth factors, and ECM expressed across various healing stages.15
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
Figure 1. A schematic diagram showing, following ‘haemostasis’, the three main stages of wound healing as it occurs in humans. The time
course reflects healing by secondary intention in a cutaneous wound, with re-epithelialisation occurring in the later proliferative phase.
The blue arrow indicates, as described in the text, the inflammatory phase that tends to persist in diabetic foot ulcers. Adapted from
Falanga.10
Characteristics of Diabetic Foot UlcersThe typical DFU is characterised by its chronicity, early and persistent inflammatory phase, delayed granulation production,and reduced ability to heal. Diabetic wounds also have a higher incidence of infection.16 Currently, a comprehensiveunderstanding of diabetic wound healing has yet to be realized.10,17 However, many important factors disrupt healing inpeople with diabetes.
Delayed healing is attributed to a variety of factors, including micro- and macrovascular disease, neuropathy, bacterialinfection, local pressure due to foot deformity, and the adverse local metabolic environment caused by diabetes.Furthermore, pathogenic factors are observed intrinsically within the wound microenvironment. These are excessiveinflammation, fibronectin deficiency, fibrin cuff accumulation, leucocyte impairment (namely persistence of neutrophils anddecrease in macrophage activity), MMP persistence,18 accumulation of advanced glycation end products (AGEs),19
abnormalities in growth factors, and other wound inflammatory mediators such as toll-like receptors (TLRs), tissue necrosisfactor alpha (TNFα) and Dipeptidyl Peptidase -4 (DPP-4).20,21,22
Chronic ulcers typically feature heavy bacterial colonisation.23 Robson et al.24 report that regardless of tissue type, any typeof bacteria present at a level equal to or greater than 106 organisms/g tissue will suffer from healing impairment. Additionally,our studies have shown that healing of DFUs are impaired even when clinically significant levels of bacteria are notdetected.25 Whether this increased bacterial burden is a consequence of the longevity of the wound, local wound hypoxicconditions, or as a direct result of hyperglycaemia or its derivatives such as advaned glycation end-products in diabetes isuncertain. Thus, infection tends to be regarded as a complication of diabetic ulcers and a factor that secondarily exacerbatesthem, as opposed to playing a primary causal role.24
Bee Products – Potential Wound Healing TherapiesBees nest in colonies that are headed by a single fertile female, the queen, who is usually the only egg layer in the colony.Worker bees are also female. They forage nectar to make honey, produce royal jelly to feed the queen and larvae, clean,remove debris from the hive, and produce the resinous substance called propolis which protects the hive from pathogens.These clearly defined functions enable the bee to survive a variety of evolutionary challenges. Numerous 'Apitherapy'products are produced by bees and can be harvested from their nests (Figure 2). Of these products, only honey, propolis,royal jelly, and bee venom have been researched for their potential as wound healing therapies. For this reason, these fourproducts are the focus of this review.
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
Royal Jelly 60% water, 5% lipids, 15%protein, 20% sugars 126
Propolis 50% resin and vegetable balsam,30% wax, 10% essential oils, 5%pollen and 5% organic debris 127,
128
Bee Venom 88% water, 6% melittin, 6%combination of other enzymesand amino acids, carbohydrates,phospholipids andphysiologically active amines 129
Figure 2. Secretions of the honeybee, Israili et al., adapted from American Journal of Therapeutics (2013)
www.americantherapeutics.com.33
The composition of bee products shows a large amount of regional variation, based on the local species of bee, plants thatthey feed on, and climatic and environmental conditions.26,27 The most well-studied and commonly used bee products aredervived from the honey bee (Apis mellifera), which is native to Europe, Africa, and Western Asia. Starting in the 17thcentury, this species has also been found around the world, including East Asia, Australia, and North and South America.28
This species of honey bee has several sub-species, or regional varieties, including the Italian bee (Apis mellifera ligustica),European dark bee (Apis mellifera mellifera), and the Carniolan honey bee (Apis mellifera carnica). Each species’ ability toproduce multiple bee products differs, with some subspecies being better suited to producing certain bee products thanothers. For example, the Russian honey bee yields more propolis than the Irish honeybee. However, most colonies canproduces one of each of these products. The principal components of the various bee products are shown in Table 1. Theyvary quite markedly in composition, including in water and carbohydrate content.
HoneyHoney is a viscous sugar solution derived from nectar and modifiedby the Apis honey bee. Since ancient times it has been used forwound healing. The use of honey in wound healing wasdocumented in the hieroglyphic text ‘The Edwin Smith Papyrus’,dated between 2600 and 2200 BC.29
Honey composition has regional variation, determined by floralsource and climate.30,31 While honey composition is variable due toregional variation in bee foodstuffs, the baseline composition of theelements remains relatively static. Honey contains over 400compounds.32 Of interest in wound healing, and discussed in moredetail later, are its antioxidant, anti-inflammatory, anti-microbial, andimmunostimulant properties.33,34 Factors contributing toantimicrobial activity of honey are high sugar concentration,hydrogen peroxide, methylglyoxal (MGO), the antimicrobial peptidebee defensin-1, and low pH. To preserve these properties, medicalgrade honey must be sterilized by gamma irradiation and notheat.35
PropolisBees produce a resinous hive protectant called propolis. The name
derives from the Greek words Pro (defense of) and Polis (city) and reflects the importance of this substance as a hiveprotectant. Propolis consists of plant buds that are collected on the hind legs of worker bees. The buds are then masticatedand mixed with salivary enzymes and wax.36 Within the hive, the bee uses propolis to fill cracks and crevices to preventinsect invasion.37 It is also used to ‘embalm’ hive invaders, which the bees are able to kill, but cannot transport out of thehive. This prevents problems associated with decomposition.36 The composition of propolis is complex and, like honey, issubject to regional variation. It contains wax, resin, and a small amount of other compounds. Most of the 200 biologically
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
active constituents of propolis38 are contained within the resin. The most biologically active fractions of propolis areflavonoids and esters of caffeic acid39,40, but recent studies have identified other promising compounds.41
Propolis is collected by scraping down the frames of the beehive, usually in winter when the bees are less active. The extractcan then be prepared a number of ways. The most common are ethanol (ethyl alcohol), ether, glycol, or water. Irrespective ofextraction method, the solution is filtered to remove the debris. It can then be diluted or mixed to form a paste or gel. Themost common forms are the ethanolic and water extracts, which contain water or alcohol soluble bactericidal components.
Royal JellyRoyal jelly is a substance of complex chemical structure produced by the young nurse bees as larval food. It is a secretionfrom glands on the top of their heads. It is harvested from movable frames where it has been deposited by the queen intoindividual queen cells. Royal jelly consists of a mixture of sugars, lipids, vitamins, and proteins secreted from the mandibularand hypopharangeal glands of worker bees.42 Significant amounts of bioactive substances such as unsaturated fatty acids of10-hydroxy-2-decenoic (10H2DA), 3,10- dihydroxydecanoic, and several insulin like peptides and sebacic acids43,44 arefound in royal jelly. Like honey and propolis, royal jelly contains phenolic compounds that are powerfully anti-oxidant.45
Many physiological functions of the royal jelly protein have been widely reported, and they possess several pharmacologicalactivities in experimental animals. These activities are immuno-modulatory, anti-inflammatory, anti-bacterial, andantioxidative.46,47 Royal jelly contains identical major proteins belonging to one protein family designated MRJP (from MajorRoyal Jelly Proteins). The family consists of five main members (MRJP1, MRJP2, MRJP3, MRJP4, and MRJP5). Theproteins MRJP3 and MRJP5 are polymorphic. MRJPs account for 82% to 90% of total larval jelly protein, and they contain arelatively high amount of essential amino acids that play an important role in honey bee nutrition.48
Bee VenomHoney bee venom is produced in the abdomen of the bee from a mixture of secretions stored in the venom sac.49 Whenadministered as a sting, it causes local inflammation, therefore, deterring predators. Bee venom also acts as ananticoagulant and releases pheromones, indicating a signaling function.50 Bee venom has been used in wound healing forcenturies. Bee venom is collected by electrically stunning the bees to remove the venom and is known for its anti-inflammatory effects. It consists of a complex mixture of peptides such as melittin, phospholipase A2, histamine,hyaluronidase, catecholamine, and serotonin.51 Melittin is the principal toxic component in the venom of the European honeybee and constitutes 50% of its dry weight.52
Biological Activities of Bee ProductsChronic foot ulcers in persons with diabetes is, as previously discussed, due to several inter-related factors that cause localwound related abnormalities.53 Some factors that prevent diabetic foot wounds from healing, including persistentinflammation and increased bacterial burden, can possibly be ameliorated with 'Apitherapy'/bee products.
The biological activities of honey, propolis, royal jelly, and bee venom are largely attributed to their phenolic compounds.Phenolic compounds exhibit a wide range of biological activities and contain one or more aromatic rings bearing one or morehydroxyl groups. They are categorized by the number of phenolic rings and the structural elements that link these rings.54
These compounds can regulate cell signaling pathways and can lead to cell proliferation and migration, as well as cellsurvival.54 Additionally, increased expression of anti-inflammatory genes and inhibition of MMP activities (particularly MMP-9)have been described.55 Phenols also have antibacterial, antifungal, antiviral, antimutagenic, and anti-inflammatory functions.The main groups of phenols in honey, propolis, and royal jelly are the flavonoids and, as discussed, regional variation withinthese compounds occurs from plant, climatic, and environmental factors.
InflammationChronic foot ulcers are often stalled in the inflammatory phase. They have impaired granulation tissue formation, persistentinflammatory cell infiltrate, and decreased ECM accumulation from either increased degradation or decreased production.Together, this dysregulation of the wound healing process leads to a delay in the proliferative stage of wound healing.
Deficient peak leucocyte numbers are noted in diabetic wounds; this is attributed to defective chemotaxis and inhibitedproliferation.56 Phenotypic changes to various leukocytes contribute to impaired wound healing, though the mechanisms bywhich these occur are largely unknown.57 In normal wounds, neutrophils are rapidly induced into the wound and are thenscarce after 72 hours. However, neutrophils persist in diabetic wounds thus prolonging the inflammatory state.58
Excess neutrophils, combined with decreased transforming growth factor beta (TGF-β) and insulin-like growth factor (IGF-1),leads to a persistent inflammatory wound environment, with the accumulation of excessive amounts of MMPs, especiallyMMP-1 and MMP-9.59 These MMPs are not matched in quantity by their regulators, the tissue inhibitors ofmetalloproteinases (TIMPs), and as a result of this inflamed, protease-enhanced environment uninhibited tissue degradationoccurs. Data from our laboratory shows that high levels of pro- and active MMP-9, and a high MMP-9 to TIMP-1 molar ratioin post-debridement wound fluid can predict future poor wound healing outcomes.18 High circulating glucose concentrationsalso increase MMP-9, but the effect of this on wound fluid MMP-9 concentration is not known.60 The ability of macrophagesto phagocytize neutrophils, a key landmark in the conclusion of the inflammatory stage, is impaired in diabetic mice.61 Thisdeficit is attributed to decreased macrophage numbers, increased levels of apoptotic neutrophils, and increased presence ofpro-inflammatory mediators. The phagocytosis of neutrophils also cues macrophages to reprogramme themselves from aninflammatory phenotype to a reparative phenotype. Lack of reprogramming can exacerbate the inflammation, therebypotentiating the cycle.62
Advanced glycation end products, or AGEs, can cause cellular ageing and also have a range of detrimental effects onwound healing.19 AGEs are formed through a series of nonenzymatic reactions, mainly between glucose and proteins.
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
Accumulation of AGE proteins in diabetic wounds is directly proportional to glycaemia and high glucose levels, indirectlyprolonging inflammation. The mechanisms by which AGE damage may occur include structural modification of proteins andstimulation of cellular responses via AGE receptors.19 AGEs may both bind to ECM and modify its function, or signal throughcell surface receptors such as the receptor for AGEs, known as RAGE, commonly to induce cellular oxidant stesspathways.19 On the basis of preclinical and clinical data, dysregulation of cytokines, MMPs, growth factor expression andinflammatory cell infiltration, and function in the diabetic wound microenvironment can be attributed to AGE activity.19
Honey has a low pH (3-4) that not only inhibits bacterial proliferation but speeds up healing through acidification. Low pHalso suppresses protease activity; a neutral pH is optimal for proteases to degrade the wound matrix.63 Low pH alsoincreases the amount of oxygen off-loaded from hemoglobin in the capillaries that reduce wound hypoxia.64 The anti-inflammatory action of honey also reduces edema and the quantity of exudate by down regulating the chronic inflammatorycycle. In studies by Majtan using keratinocytes, after incubation with honey elevated production of mediators includingcytokines (TNF-α and TGF-β) and MMP-9 was shown.65 Whether this observation can be transferred to the complex woundhealing environment with positive or negative effect is not clear, and it is likely dependent on the phase of the wound healingprocess.
The anti-inflammatory effects of propolis are well-established.66,67 These properties are largely attributable to caffeicacid.68,69 Studies by Jin et al.70 showed that caffeic acid phenyl ester (CAPE) in propolis is a potent inhibitor of MMP-9.Temiz et al.71 hypothesised that propolis treated rat colon anastomoses healed more quickly and showed increased burstingstrength due to decreased collagenolysis attributable to CAPE action on MMP-9. Our laboratory was the first to report theuse of topical propolis in a diabetic animal model of wound healing. McLennan et al. showed that propolis treatment reducedthe persistent inflammation that characterizes diabetic wounds by normalizing neutrophil and neutrophil elastase counts.McLennan et al. proposed that the widely reported anti-oxidant effects of propolis73,74,75 normalized inflammatory exudates indiabetic rodents and aided the observed improvement in wound closure rate in diabetic wounds.
Reduced inflammatory cell activity was observed in propolis treated rabbit eye corneal injuries compared to controls. Thisanti-inflammatory effect was comparable to the anti-inflammatory effect of dexamethasone.76 Mice treated with propolis(200mg/kg) showed an inhibition of interleukins produced by spleen cells. This demonstrated the potential of propolis toreduce the chronic inflammation that characterizes many autoimmune diseases.77
The major fatty acid component of royal jelly, 10H2DA, has collagen synthetic and MMP-inhibitory activities.78 Royal jellyprotein prolonged the cell proliferation of primary cultured rat hepatocytes,79 enhanced the migration of cultured humandermal fibroblasts,80 improved granulation tissue formation, and improved dermal wound healing rate in diabetic rats.78
Bee venom constituents demonstrate anti-inflammatory properties, and it is traditionally used in many inflammatory chronicconditions. Nonetheless, its mechanism of action at the molecular level is not fully understood. In the liver, melittin – the maincomponent of bee venom – is able to suppress the expression of pro-inflammatory cytokines through the nuclear factorkappa-beta (NF)–κβ signaling pathway. Moreover, melittin reduces the activity of Hepatic Stellate Cells (HSCs) in vitro anddecreases the expression of fibrotic gene responses in thioacetamide-induced liver fibrosis.81
Work by Kwon et al. has demonstrated that peripheral injection of bee venom significantly reduces or prevents thedevelopment of an inflammatory response in human arthritic disease.82 Bee venom injection into the left hind limb reducesleukocyte migration in a zymosan-induced peripheral inflammation model.83 Amin et al. suggest that some components ofbee venom can cause inflammation by inducing interleukin 1 beta (IL-1β ) via a mitogen-activated protein kinase pathway:p38 MAPK, while others act as anti-inflammatory by suppressing inducible nitric oxide synthase (iNOS) andCyclooxygenase-2 (COX2) via (NF)–κβ in macrophages.84 A more recent study by the same group using bee venom cross-linked to a hydrogel showed administration of this gel decreased inflammatory response and IL-6 production, and increasedcollagen formation in wounds in diabetic rabbits.85
Oxidative StressEvidence suggests a link between oxidative stress and cellular damage and various diabetes associated complications. Lossof antioxidant defenses, together with a superfluous production of reactive oxygen species (ROS), play a crucial mediatoryrole in the pathogenesis and progression of chronic non healing diabetic wounds.
Honey contains antioxidants that scavenge free radicals.86 The antioxidant potential of honey has been attributed to itsphenolic content.87 The high phenolic content of propolis has also been linked to its anti-oxidant properties. Studies bySulaiman showed the free radical scavenging activities of propolis samples were strong when also evaluated by using the2,2-diphenyl-1-picrylhydrazyl assay.88 In a rat model of ischemic reperfusion injury, abundant amounts of ROS are produced,and CAPE, an active ingredient of honey bee propolis, was able to reduce tissue damage via its antioxidant effects.89
Enzymatic hydrolysates prepared from royal jelly showed anti-oxidative activity and scavenging activity against ROS.90 In aseparate series of studies, royal jelly time of harvest and the initial larval age had an effect on the antioxidant potencies inroyal jelly. Royal jelly collected 24 hours after the larval transfer showed the most substantial antioxidant activities.91 Fewstudies exist that explore the anti-oxidant potential of bee venom. In vitro studies by Rekka et al. showed that suppression ofinterleukin-1 production, offered by bee venom, may further support the theory that antioxidant activity is a mechanism of theanti-inflammatory activity of bee venom.92 Bee venom was also shown to significantly decrease the level of ROS inducedoxidative damage to synovial fluid proteins in a rat model of rheumatoid arthritis.93
Bacterial BurdenIncreased bacterial burden and wound infection are common in patients with diabetes and play an important role in ulcerchronicity. Honey has been shown to potently inhibit a range of bacterial pathogens, including Staphylococcus aureus,Escherichia coli, Pseudomonas aeruginosa, and methicillin-resistant staphylococcus aureus (MRSA).94,95 Honey has alsobeen shown to work synergistically with systemic antibiotics and to have a low rate of adverse effects (occasional allergic
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
reaction).96 Honey promotes wound healing through regulating the moisture and preventing maceration balance in thewound bed via osmosis.97 Its osomtic properties are also sufficient to inhibit microbial growth through dehydration oforganisms.59,97 Honey types that have a moderate level of antibacterial activity prevented the growth of Staphylococcusaureus if diluted beyond the point where their osmolality ceased to be inhibitory. Thus, the antibacterial activity cannotentirely be attributable to osmolality.98
Aside from its osmotic effect, honey exhibits multiple anti-bacterial effects. When honey is diluted by wound exudate,hydrogen peroxide is produced by the enzyme glucose oxidase.99 Hydrogen peroxide is an effective antimicrobial agentwhen present at a sufficiently high concentration.100 It also stimulates fibroblast proliferation in vitro and angiogenesis invivo.101,102 Phytochemicals, also known as flavonoids, are other antibacterial components of honey.103 These compoundsare found in high concentrations in commonly used therapeutic honeys (Manuka and Medihoney®) compared to otherhoneys. Various honeys have substantial non-peroxide antibacterial activity. Manuka honey, which is potently antibacterial,does not accumulate any hydrogen peroxide (H2O2).104 Manuka honey does, however, contain high levels of theantimicrobial compound methylglyoxal (MGO). The potential of this honey to inhibit the growth of S. aureus suggests thatMGO is fully responsible for the non-peroxide antibacterial activity of Manuka honey.105
Robust evidence supports the anti-microbial properties of propolis.106 Propolis has an inhibitory concentration that is 400times greater than tetracycline’s against E. coli and more than 50 times higher than tetracycline’s against S. aureus and B.subtilis. Microcalorimetric analysis of propolis treated M. Luteus bacterial cultures was performed different growth phases.The addition of prepared propolis extracts to these cultures resulted in a strong decline in heat production, a prolongation ofthe lag phase, and the introduction of a second lag phase indicating that the effects of propolis are both bacteriostatic andbacteriocidal.107 The anti-bacterial activity of propolis is largely attributable to the phenolic acid fraction. Studies showed thatno antibacterial activity against S. aureus was observed in a batch of propolis with a low phenol count compared to batcheswith a higher phenol count.108 Propolis also inhibits the proliferation of fungal elements, such as Candida (at concentrationsof 3-10mg/m)109 and viruses.
Royal jelly shows inhibitory actions against Gram-positive bacterial strains Bacillus subtilis, Micrococcus flavus, andStaphylococcus aureus in a microplate assay, while showing no significant effect against gram negative bacteria.110,111
Studies also showed that a royal jelly and starch mixture could be used to treat conventional drug resistant infections, andfreshly reaped royal jelly was antimicrobial against Pseudomonas aeruginosa.112,113
Bee venom has antibacterial properties.114,115 Studies by Han et al. that investigated the antibacterial activity of whole beevenom and purified melittin against Escherichia coli and Staphylococcus aureus in cow mastitis found it to be an effectiveantibacterial agent.116 Lasioglossin-III is a new anti-microbial peptide (AMP) discovered in the venom of the Lasioglossumlaticeps bee. It possesses broad spectrum antimicrobial activity against both Gram-positive and Gram-negative bacteria andhas a low toxicity in solution.
ImmunomodulationA relative lymphocyte response defect has been reported in chronic DFUs.117 Consequently, the DFU healing process maybe hampered by mechanisms which cause a decrease in the accumulation of leukocytes.117 The immune-modulatory effectsof honey include proliferation of peripheral blood B-lymphocytes and T-lymphocytes in cell culture at concentrations as lowas 0.1% and phagocyte activation by honey at concentrations as low as 0.1%.118 Propolis mediated inhibition of the p24antigen by the human immunodeficiency (HIV) virus infected CD4(+) cells has also been observed.119 Royal jelly proteinsMRJP1 and MRJP2 stimulate mouse macrophages to release TNF-a, whose primary function is to regulate immune cells,120
whilst MRJP3 is able to modulate immune responses by suppressing the production of interluekins: IL-4, IL-2, and IFN-c in Tcells.121
Clinical Trials of 'Apitherapy' Products on Diabetic foot ulcersRecently, many publications have attempted to quantify the efficacy of bee products as wound healing therapies using avariety of different wounds. Most clinical trials, in the context of 'Apitherapy', investigate the wound healing potential ofhoney. The healing deficiencies observed within DFUs have been long established. Promising pre-clinical data suggests thatbee products may expedite these healing deficiencies, yet few clinical trials exist which investigate the effects of bee producttherapies on DFUs. Table 2 lists summaries and associated case studies.
Current evidence for using bee products on human DFUs is promising but weak. The studies are small, often anecdotal, andnon-randomized. They also frequently lack controls. More robust trials are needed for such therapies to be accepted as anevidence-based treatment. Similarly, the Cochrane review of the randomized controlled trials (RCT) and quasi RCTs ofhoney used in chronic ulcers (including diabetic ulcers) was critical of the studies, citing broad inclusion criteria and failure toreport on randomization as potential sources of bias.122 Jull et al. concluded that:
‘Honey dressings do not increase rates of healing significantly in venous leg ulcers when used as an adjuvant tocompression. Honey may delay healing in partial- and full-thickness burns in comparison to early excision and grafting, andin cutaneous Leishmaniasis when used as an adjuvant with meglumine antimoniate. Honey might be superior to someconventional dressing materials, but there is considerable uncertainty about the reproducibility and applicability of thisevidence.’
Table 2. Summary of clinical trials that have investigated the use of bee products to heal wounds. ‘C’ refers to the respective controls and
‘H’ to the type (if known) of honey used in the study.
Intervention Author/Year/ Reference
ExperimentalDesign
Cohort Therapy Outcome
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
Honey more effective thanPyodine dressings;increased healing rate; lowamputation rate in honeygroup, but did not reachstatistical significance
Makhdoom etal. 2009130
Quasiexperimentalstudy
n=14 H=14
H= Honey soakeddressings
‘Excellent results’ reported;however, no timeframe orcontrol group reported; 12/14underwent amputation
Eddy et al.2008131
Case study n=1 H= Honeysmeared gauze
Ulcers that had beenunhealed for 14 month;despite intensive treatment,healed in 6-12 months andremained healed after 2 years
Kamaratos etal. 2010132
Randomizedcontrolled trial
n=63 (n pergroup notstated)
H= Manuka honeydressingsC=Conventionaldressings
Honey treated ulcers healedin an average of 31 days;control wounds healed in anaverage of 43 days; P=0.05
Shukrimi et al.2008136
Randomizedcontrolled trial
n=30 (n pergroup notstated)
H=Honey dressing C= PovidoneIodine and saline
No significant differences inhealing between groups;ulcers were healedadequately in 14.4 and 15.4days respectively, to be readyfor surgical closure
Propolis Hossein et al.2012133
Case study n=1 P=Propolis +Olive oil
Ulcer of 2 months durationhealed within 1 week
Royal Jelly Sivash et al.2011134
Quasiexperimentalstudy
n=8 R=Royal jelly Mean healing time = 41 days;were fully 7/8 healed
Sivash et al.2013135
Randomizedcontrolled trial
n=64 R=32; C=32
R=5% Royal jelly C= Placebo
No significant superiority toroyal jelly treatment; RJtreated wounds healed in anaverage of 36 days comparedto 38 days in controls; P=0.6
CONCLUSIONCurrent pre-clinical research in the field of 'Apitherapy' products in wound healing suggests that honey, propolis, royal jelly,and bee venom are safe. They also have the potential to not only upregulate healing in ‘normal wounds’ but also to attenuatethe chronic inflammation, oxidative stress, bacterial burden, and immunodeficiency that thwarts healing in diabeticwounds.123, 124, 125 The potential for bee products to be used as wound healing therapies has been established in terms ofpre-clinical work, but more rigorous testing in the clinical setting is needed.
Within the hive ecosystem, honey and royal jelly are foodstuffs; bee venom is involved in defensive roles (killing intruders)and signaling (releasing pheromones that warn other bees of attack). The primary function of propolis is to protect beesagainst disease. Bees coat the internal walls of their hives with a thin layer of propolis to sterilize the comb and keep theirhives bacteria free. Given this specific function, and that it has proven effective in pre-clinical studies, it is likely that amongall bee products, propolis holds the greatest potential as a wound healing product.126
A lack of large-scale, well-conceived, robust clinical trials precludes bee products from becoming more accepted as woundtherapies. Given the magnitude of diabetic foot ulcerations, there is an urgent need to systematically study bee products inhuman DFUs to determine if any may improve healing outcomes.
References1. Goodson WH 3rd, Hung TK. Studies of wound healing in experimental diabetes mellitus.J Surg Res. 1977;22(3):221-227.
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
2. Bharara M, Schoess J, Armstrong DG. Coming events cast their shadows before: detecting inflammation in the acutediabetic foot and the foot in remission.Diabetes Metab Res Rev.2012;1:15-20.
3. Margolis DJ, Hoffstad O, Nafash J, Leanard CE, Freeman CP, Hennessey S, Wiebe DJ. Location, location, location:Geographic clustering of lower-extremity amputation among medicare beneficiaries with diabetes.Diabetes Care.2011;34(11):2363-2367.
4. Reiber GE, Vileikyte L, Boyko EJ, del Aguila M, Smith DG, Lavery LA, Boulton AJ . Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings.Diabetes Care. 1999;22(1)157-162.
5. Cavanagh P, Attinger C, Abbas Z, Bal A, Rojas N, Xu ZR. Cost of treating diabetic foot ulcers in five differentcountries.Diabetes Metab Res Rev. 2012;.1:.107-111.
6. Davis TM, Bruce DG, Davis WA. Cohort profile: The Fremantle Diabetes Study.Int J Epidemiol. 2013;42(2):412-421.
7. Galkowska H, Wojewodzka U, Olszewski WL. Chemokines, cytokines, and growth factors in keratinocytes and dermalendothelial cells in the margin of chronic diabetic foot ulcers.Wound Repair Regen. 2006;14(5):558-565.
8. Lobmann R, Ambrosch A, Schultz G, Waldmann K, Schiweck S, Lenhert H. Expression of matrix-metalloproteinases andtheir inhibitors in the wounds of diabetic and non-diabetic patients.Diabetologia. 2002;45(7):1011-1016.
9. Maruyama K, Asai J, Li M, Thorne T, Losordo DW, D'Amore PA. Decreased macrophage number and activation lead toreduced lymphatic vessel formation and contribute to impaired diabetic wound healing.Am J Pathol. 2007;170(4):1178-1191.
10. Falanga V. Wound healing and its impairment in the diabetic foot.Lancet 2005;366(9498):1736-1743.
11. Boulton AJ, Meneses P, Ennis WJ. Diabetic foot ulcers: A framework for prevention and care.Wound Repair Regen.1999;7(1):7-16.
12. Tan T, Shaw EJ, Siddiqui F, Kandaswamy P, Barry PW, Baker P. Inpatient management of diabetic foot problems:summary of NICE guidance.BMJ. 2011;342.
13. Martinez-Zapata M.J, Martí-Carvajal AJ, Solà I, Expósito JA, Bolíbar I, Rodríguez L, Garcia J. Autologous platelet-richplasma for treating chronic wounds.Cochrane Database Syst Rev.2012:17(10).
14. Barrientos S, Stojadinovic O, Golinko MS, Brem H, Tomic-Canic M. Growth factors and cytokines in woundhealing.Wound Repair Regen. 2008;16(5):585-601.
15. Schultz GS, Davidson JM, Kirnser RS, Bornstein P, Herman IM. Dynamic reciprocity in the woundmicroenvironment.Wound Repair Regen. 2011;19(2):134-148.
16. Gupta SK, Singh SK. Diabetic foot: a continuing challenge.Adv Exp Med Biol. 2012;771:123-138.
17. Waugh HV, Sherratt JA. Modeling the effects of treating diabetic wounds with engineered skin substitutes.Wound RepairRegen 2007;15(4):556-565.
18. Liu Y, Min D, Bolton T, Nube V, Twigg SM, Yue DK, McLennan SV. Increased matrix metalloproteinase-9 predicts poorwound healing in diabetic foot ulcers.Diabetes Care. 2009;32(1):117-119.
19. Schmidt AM, Yan SD, Wautier JL, Stern D. Activation of Receptor for Advanced Glycation End Products: A Mechanismfor Chronic Vascular Dysfunction in Diabetic Vasculopathy and Atherosclerosis.Circulation Research 1999;84(5):489-497.
20. Dasu MR, Devaraj S, Park S, Jialal I. Increased toll-like receptor (TLR) activation and TLR ligands in recently diagnosedtype 2 diabetic subjects.Diabetes Care. 2010;33(4):861-868
21. Landis RC, Evans BJ, Chaturvedi N, Haskard DO. Persistence of TNFalpha in diabetic wounds.Diabetologia.2010;53(7):1537-1538.
22. Schürmann C, Linke A, Engelmann-Pilger K, Steinmetz C, Mark M, Pfeilschiffer J, Klein T, Frank S. The dipeptidylpeptidase-4 inhibitor linagliptin attenuates inflammation and accelerates epithelialization in wounds of diabetic ob/ob mice.JPharmacol Exp Ther. 2012;342(1):71-80.
23. Schneider M, Vildozola CW, Brooks S. Quantitative assessment of bacterial invasion of chronic ulcers. Statisticalanalysis.Am J Surg. 1983;145(2):260-262.
24. Robson MC, Heggers JP. Delayed wound closure based on bacterial counts.J Surg Oncol.1970;2(4):379-383.
25. Xu L, McLennan SV, Lo L, Natfaji A, Bolton T, Liu Y, Twigg SM, Yue DK. Bacterial load predicts healing rate inneuropathic diabetic foot ulcers.Diabetes Care. 2007;30(2):378-380.
26. Righi AA, Negri G, Salatino A. Comparative chemistry of propolis from eight brazilian localities.Evid Based ComplementAlternat Med. 2013;267878(10):
27. Gheldof N, Engeseth NJ. Antioxidant capacity of honeys from various floral sources based on the determination ofoxygen radical absorbance capacity and inhibition of in vitro lipoprotein oxidation in human serum samples.J Agric FoodChem. 2002;50(10):3050-3055
28. Winston MJ, Dropkin J, Taylor O. Demography and life history characteristics of two honey bee races (Apismellifera).Oecologia. 1981;48(3):407-413.29.
29. Breasted JH, The Edwin Smith surgical papyrus: Hieroglyphic transliteration, translation and commentary.KessingerPublishing. 2006;Vol.(1).
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
30. Manyi-Loh CE, Ndip RN, Clarke AM. Volatile compounds in honey: A review on their involvement in aroma, botanicalorigin determination and potential biomedical activities.Int J Mol Sci. 2011;12(12):9514-9532.
31. Chang X, Wang J, Yang S, Chen S, Song Y. Antioxidative, antibrowning and antibacterial activities of sixteen floralhoneys.Food Funct. 2011;2(9):541-546.
32. Bentivenga G, Racioppi R. SPME-GC-MS analysis of volatile organic compounds in honey from Basilicata. Evidence forthe presence of pollutants from anthropogenic activities.International Journal of Food Science and Technology.2004;39(10):1079-1086.
33. Israili ZH. Antimicrobial properties of honey.Am J Ther. 2013;Epub ahead of print.
34. Al-Waili N, Salom K, Al-Ghamdi AA. Honey for Wound Healing, Ulcers, and Burns; Data Supporting Its Use in ClinicalPractice.Scientific World Journal. 2011;11:766-787.
35. Pieper B. Commentary " Honey: a potent agent for wound healing? ".J Wound Ostomy Continence Nurs.2002;29(6):273-274.
36. Bankova VS, de Castro SL, Marcucci MC. Propolis: recent advances in research on chemistry and plantorigin.Apidologie. 2000;31(1):3-15.
37. Daugsch A, Moraes CS, Fort P, Park YK. Brazilian Red PropolisChemical Composition and Botanical Origin.Evid BasedComplement Alternat Med. 2008;5(4):435-441.
38. Marcucci MC. Propolis: chemical composition, biological properties and therapeutic activity.Apidologie. 1995;26(2):83-99.
39. Banskota AH, Nagaoka T, Sumioka LY, Tezuka Y, Awale S, Midorikawa K, Matsushigue K, Kadota S. Antiproliferativeactivity of the Netherlands propolis and its active principles in cancer cell lines.J Ethnopharmacol. 2002;80(1):67-73.
40. Russo A, Longo R, Vanella A. Antioxidant activity of propolis: role of caffeic acid phenethyl ester andgalangin.Fitoterapia. 2002;73,Supplement1(0):S21-9.
41. Salatino A, Fernandes-Silva CC, Righi AA, Salatino ML. Propolis research and the chemistry of plant products.Nat ProdRep. 2011;28(5):925-936.
42. Cherniack EP. Bugs as drugs, part 1: Insects. The "new" alternative medicine for the 21st century?Altern Med Rev.2010;15(2):124-135.
43. Caparica-Santos C, Marcucci MC. Quantitative determination of trans-10-Hydroxy-2-Decenoic Acid (10-HDA) in Brazilianroyal jelly and commercial products containing royal jelly.Journal of Apicultural Research and Bee World. 2007;46(3):149-153.
44. Kramer KJ, Tager HS, Childs CN, Spiers RD. Insulin-like hypoglycemic and immunological activities in honeybee royaljelly.J Insect Physiol. 1977;23(2):293-295.
45. Buratti S, Benedetti S, Cosio MS. Evaluation of the antioxidant power of honey, propolis and royal jelly by amperometricflow injection analysis.Talanta. 2007;71(3):1387-1392.
46. Park HM, Cho MH, Cho Y, Kim SY. Royal jelly increases collagen production in rat skin after ovariectomy.J Med Food.2012;15(6):568-575.
47. Shinoda M, Nakajin S, Oikawa T, Sato K, Kamogawa A, Akjama Y. Biochemical studies on vasodilative factor in royaljelly (author's translation).Yakugaku Zasshi. 1978;98(2):139-145.
48. Schmitzova J, Klaudinv J, Albert S, Schroder W, Schreckengost W, Hanes J, Judova J, Simuth J. A family of major royaljelly proteins of the honeybee Apis mellifera L.Cell Mol Life Sci.1998;54(9):1020-1230.
49. Habermann E. Bee and wasp venoms.Science 1972;177(4046):314-322
50. Peiren N, de Graaf DC, Vanrobaeys F, Danneels EL, Devresse B, Van Beeumen J, Jacobs FJ. Proteomic analysis of thehoney bee worker venom gland focusing on the mechanisms of protection against tissue damage.Toxicon. 2008;52(1):72-83.
52. Dempsey CE. The actions of melittin on membranes.Biochim Biophys Acta 1990;7(2):143-161.
53. Sibbald GR, Woo KY. The biology of chronic foot ulcers in persons with diabetes.Diabetes Metab Res Rev.2008;24(1):847
54. Fresco P, Borges F, Diniz C, Marques MP. New insights on the anticancer properties of dietary polyphenols.Med ResRev. 2006;26(6):747-766.
55. Majtan J, Kumar P, Majtan T, Walls AF, Klaudiny J. Effect of honey and its major royal jelly protein 1 on cytokine andMMP-9 mRNA transcripts in human keratinocytes.Exp Dermatol. 2010;19(8):1600-1625.
56. Pierce GF. Inflammation in nonhealing diabetic wounds: the space-time continuum does matter.Am J Pathol.2001;159(2):399-403.
57. Loots MA, Lamme EN, Zeegelaar J, Mekkes JR, Bos JD, Middelloop E. Differences in cellular infiltrate and extracellularmatrix of chronic diabetic and venous ulcers versus acute wounds.J Invest Dermatol.1998;111(5):850-857.
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
58. Wetzler C, Kampfer H, Stallmeyer B, Pfeilschifter J, Frank F. Large and sustained induction of chemokines duringimpaired wound healing in the genetically diabetic mouse: prolonged persistence of neutrophils and macrophages during thelate phase of repair.J Invest Dermatol.2000;115(2):245-253.
59. Chirife J, Herszage L, Joseph A, Kohn ES. In vitro study of bacterial growth inhibition in concentrated sugar solutions:microbiological basis for the use of sugar in treating infected wounds. Antimicrob Agents Chemother.1983;23(5):766-773
60. Schleicher E, Friess U. Oxidative stress, AGE, and atherosclerosis.Kidney Int Suppl2007;72(S106):S17-S26.
61. O’Brien BA, Huang Y, Geng X, Dutz JP, Finegood DT. Phagocytosis of Apoptotic Cells by Macrophages From NOD MiceIs Reduced.Diabetes. 2002;51(8):2481-2488.
62. Mosser DM, Edwards JP. Exploring the full spectrum of macrophage activation.Nat Rev Immunol. 2010;10(6):460.
63. Rushton I., Understanding the role of proteases and pH in wound healing.Nursing stand.2007;21(32);68,70,72.
64. Schneider LA, Korber A, Grabbe S, Dissemonde J. Influence of pH on wound-healing: A new perspective for wound-therapy?Arch Dermatol Res. 2007;298(9):413-420.
65 Majtan J, Kumar P, Majtan T, Walls AF, Klaudiny J. Effect of honey and its major royal jelly protein 1 on cytokine andMMP-9 mRNA transcripts in human keratinocytes.Exp Dermato. 2010Aug;19(8):e73-9.
66. Mirzoeva OK, Calder PC. The effect of propolis and its components on eicosanoid production during the inflammatoryresponse.Prostaglandins Leukot Essent Fatty Acids. 1996;55(6):441-449.
67. Sforcin JM. Propolis and the immune system: a review.J Ethnopharmacol2007;113(1):1-14.
68. Grunberger D, Banerjee R, Eisinger K, Oltz EM, Efros L, Caldwell M, Estevez V, Nakanishi K. Preferential cytotoxicity ontumor cells by caffeic acid phenethyl ester isolated from propolis.Experientia. 1988;44(3):230-32.
69. Chan WS, Wen PC, Chiang HC. Structure-activity relationship of caffeic acid analogues on xanthine oxidaseinhibition.Anticancer Res. 1995;15(3):703-707
70. Jin UH, Chung TW, Kang SK, Suh SJ, Chung KH, Gu YH, Suzuki I, Kim CH.Caffeic acid phenyl ester in propolis is astrong inhibitor of matrix metalloproteinase-9 and invasion inhibitor: Isolation and identification.Clin Chim Acta. 2005;362(1-2):57-64.
71. Temiz M, Aslan A, Canbolant E, Hakverdi S, Polat G, Uzan S, Temiz A, Gonenci R. Effect of propolis on healing inexperimental colon anastomosis in rats.Adv Ther. 2008;25(2):159-167.
72. McLennan SV, Bonner J, Milne S, Lo L, Charlton A, Kurup S, Jia J, Yue DK, Twigg SM. Propolis, the anti-inflammatorybee hive protectant prevents increased matrix metalloproteinase-9 (MMP-9) levels in wound healing in experimentaldiabetes.Wound Repair Regen. 2009;17(2):A50.
73. Mercan N, Kivrak I, Duru ME, Katirciolglu H, Gulcan S, Malci S, Salih B. Chemical composition effects onto antimicrobialand antioxidant activities of propolis collected from different regions of Turkey.Annals of Microbiology. 2006;56(4):373-378.
74. Nagaoka T, Banskota AH, Tezuka Y, Saiki I, Kadota S. Selective antiproliferative activity of caffeic acid phenethyl esteranalogues on highly liver-metastatic murine colon 26-L5 carcinoma cell line.Bioorg Med Chem 2002;10(10):3351-3359.
75. Vieira O, Laranjinha J, Madeira V, Almeida L. Cholesteryl ester hydroperoxide formation in myoglobin-catalyzed lowdensity lipoprotein oxidation – Concerted antioxidant activity of caffeic and p-coumaric acids with ascorbate.BiochemPharmacol. 1998;55(3):333-340.
76. Ozturk F, Kurt E, Cerci M, Emiroglu L, Iuan U, Turker M, Ilker S. The effect of propolis extract in experimental chemicalcorneal injury.Ophthalmic Res. 2000;32(1):13-18.
77. Missima F, Sforcin JM. Green Brazilian propolis action on macrophages and lymphoid organs of chronically stressedmice.Evid Based Complement Alternat Med.2008;5(1):71-75.
78. Fujii A, Kobayashi S, Kuboyama N, Furukawa Y, Kaneko Y, Ishihama S, Tamura T. Augmentation of wound healing byroyal jelly (RJ) in streptozotocin-diabetic rats.Jpn J Pharmacol.1990;53(3):331-337.
79. Kamakura M, Suenobu N, Fukushima M. Fifty-seven-kDa protein in royal jelly enhances proliferation of primary culturedrat hepatocytes and increases albumin production in the absence of serum.Biochem Biophys Res Commun.2001;282(4):865-874.
80. Kim J, Kim Y, Yun H, Park H, Kim SY, Lee KG, Han SM, Cho Y. Royal jelly enhances migration of human dermalfibroblasts and alters the levels of cholesterol and sphinganine in an in vitro wound healing model.Nutr ResPract.2010;4(5):362-368.
81. Park JH, Kum YS, Lee TI, Kim SJ, Lee WR, Kim BI, Kim HS, Kim KH, Park KK. Melittin attenuates liver injury inthioacetamide-treated mice through modulating inflammation and fibrogenesis.Exp Biol Med. 2011;236(11):1306-1313.
82. Kwon YB, Lee HJ, Han HJ, Mar WC, Kang SK, Yoon OB, Beitz AJ, Lee JH. The water-soluble fraction of bee venomproduces antinociceptive and anti-inflammatory effects on rheumatoid arthritis in rats.Life Sci.2002;71(2):191-204
83. Kwon YB, Kim HW, Ham TW, Yoon SY, Roh DH, Han HJ, Beitz AJ, Yang IS, Lee JH.The anti-inflammatory effect of beevenom stimulation in a mouse air pouch model is mediated by adrenal medullary activity.J Neuroendocrinol. 2003;15(1):93-96.
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
84. Amin MA, Abdel-Raheem IT, Madkor HR. Wound healing and anti-inflammatory activities of bee venom-chitosan blendfilms.J Drug Del Sci Sci Tech. 2008;18(6):424-430.
85. Amin MA, Abdel-Raheem IT. Accelerated wound healing and anti-inflammatory effects of physically cross linked polyvinylalcohol-chitosan hydrogel containing honey bee venom in diabetic rats.Arch Pharm Res. 2013;30:30.
86. van den Berg AJ, van den Worm E, van Ulfford HC, Halkes SB, Hoekstra MJ, Beukelman CJ. An in vitro examination ofthe antioxidant and anti-inflammatory properties of buckwheat honey.J Wound Care. 2008;17(4):172-174,176-178.
87. Kassim M, Achoui M, Mustafa MR, Mohd MA, Yusoff KM. Ellagic acid, phenolic acids, and flavonoids in Malaysian honeyextracts demonstrate in vitro anti-inflammatory activity.Nutr Res. 2010;30(9):650-659.
88. Sulaiman GM, Sammarrae KWA, Ad’hiah AH, Zucchetti M, Frapolli R, Bello E, Erba E, D’Incalci M, Bagnati R. Chemicalcharacterization of Iraqi propolis samples and assessing their antioxidant potentials.Food Chem Toxicol. 2011;49(9):2415-2421.
89. Bilen BT, et al. Effect of caffeic acid phenethyl ester on survival of axial pattern flaps in rats with ischaemia-reperfusioninjuries.Scand J Plast Reconstr Surg Hand Surg. 2006;40(2):73-78.
90. Nagai T, Inoue R, Suzuki N, Nagashima T. Antioxidant properties of enzymatic hydrolysates from royal jelly.J MedFood.2006;9(3):363-367.
91. Liu JR, Yang YC, Shi LS, Peng CC. Antioxidant properties of royal jelly associated with larval age and time of harvest.JAgric Food Chem. 2008;56(23):11447-11452.
92. Rekka E, Kourounakis L, Kourounakis P. Antioxidant activity of and interleukin production affected by Honey BeeVenom.Arzneimittel-Forschung/Drug Research. 1990;40(8):912-913.
93. Suh SJ, Kim KS, Kim MJ, Chang YC, Lee SD, Kim MS, Kwon DY, Kim CH. Effects of bee venom on protease activitiesand free radical damages in synovial fluid from type II collagen-induced rheumatoid arthritis rats.Toxicol in Vitro.2006;20(8):1465-1471.
94. Sherlock O, Dolan A, Athman R, Power A, Gethin G, Cowman S, Humphreys H. Comparison of the antimicrobial activityof Ulmo honey from Chile and Manuka honey against methicillin-resistant Staphylococcus aureus, Escherichia coli andPseudomonas aeruginosa.BMC Complement Altern Med. 2010;10.
95. Gethin G, Cowman S. Bacteriological changes in sloughy venous leg ulcers treated with manuka honey or hydrogel: anRCT.J Wound Care.2008;17(6): 241-244,246-247.
96. Biglari B, Moghaddam A, Santos K, Blaser G, Büchler A, Jansen G, Längler A, Graf N, Weiler U, Licht V, Strölin A, KeckB, Lauf V, Bode U, Swing T, Hanano R, Schwarz NT, Simon A. Multicentre prospective observational study on professionalwound care using honey (Medihoney™).Int Wound J.2013;10(3):252-259.
97. Namias N. Honey in the management of infections.Surg Infect2003;4(2):219-226.
98. Cooper RA, Molan PC, Harding KG. Antibacterial activity of honey against strains of Staphylococcus aureus frominfected wounds.J R Soc Med.1999;92(6):283-285.
99. Vandamme L, Heyneman A, Hoeksema H, Verbelen J, Monstrey S. Honey in modern wound care: A systematicreview.Burns 2013;39(8):1514-1525.
100. Bang LM, Buntting C, Molan P. The effect of dilution on the rate of hydrogen peroxide production in honey and itsimplications for wound healing.J Altern Complement Med.2003;9(2):267-273.
101. Tur E, Bolton L, Constantine BE. Topical hydrogen peroxide treatment of ischemic ulcers in the guinea pig: Bloodrecruitment in multiple skin sites.J Am Acad Dermatol.1995;33(2I):217-221.
102. Burdon RH. Superoxide and hydrogen peroxide in relation to mammalian cell proliferation.Free Radic Biol Med.1995;18(4):775-794.
103. Bansal V, Medhi B, Pandhi P. Honey – A remedy rediscovered and its therapeutic utility.Kathmandu Univ MedJ.2005;3no.3(11):305-309.
104. Allen KL, Molan PC, Reid GM. A survey of the antibacterial activity of some New Zealand honeys.J PharmPharmacol.1991;43(12):817-822.
105. Adams CJ, Boult CH, Deadman BJ, Farr JM, Grainger MN, Manley-Harris M, Snow MJ. Isolation by HPLC andcharacterisation of the bioactive fraction of New Zealand manuka (Leptospermum scoparium) honey.CarbohydrRes.2008;343(4):651-659.
106. Bonvehi JS, Coll FV, Jorda RE. The composition, active compnents and bacteriostatic activity of propolis indietetics.Journal of the American Oil Chemists Society. 1994;71(5):529-532.
107. Lamprecht I. Calorimetric investigations around a royal hieroglyph.Thermochimica Acta. 1994;234:179-200[DOI:10.1016/0040-6031(94)85143-3]
108. Bankova V, Christov R, Kujumgiev A, Marcucci MC, Popova S. Chemical composition and antibacterial activity ofbrazilian propolis. Z Naturforsch C.1995;50(3-4):167-172.
109. Metzner J, Schneidewind EM, Friedrich E. Effects of propolis and pinocembrin on blastomyces.Pharmazie1977;32(11):730.
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
110. Shen L, Liu D, Li M, Jin F, Din M, Parnell LD, Lai C-Q. Mechanism of Action of Recombinant Acc-Royalisin from RoyalJelly of Asian Honeybee against Gram-Positive Bacteria.PLoS One. 2012;7(10):e47194.
111. Fujiwara S, Imai J, Fujiwara M, Yaeshima T, Kawashima T, Kobayashi K. A potent antibacterial protein in royal jelly.Purification and determination of the primary structure of royalisin.J Biol Chem. 1990;265(19):11333-11337.
112. Boukraa L. Additive activity of royal jelly and honey against Pseudomonas aeruginosa.Altern Med Rev. 2008;13(4):330-333.
113. Boukraĝ L, Meslem A, Benhanifia M, Hammoudi SM. Synergistic effect of starch and royal jelly against staphylococcusaureus and escherichia coli.J Altern Complement Med. 2009;15(7):755-757.
114. Fennell JF, Shipman WH, Cole LJ. Antibacterial action of melittin, a polypeptide from bee venom.Proc Soc Exp BiolMed. 1968;127(3):707-710.
115. Fennell JF, Shipman WH, Cole LJ. Antibacterial action of a bee venom fraction (melittin) against a penicillin-resistantstaphylococcus and other microorganisms. USNRDL-TR-67-101.Res Dev Tech Rep. 1967; 5:1-13.116.
116. Han S, Yeo J, Baek H, Lin S-M, Meyer S, Molan P. Postantibiotic effect of purified melittin from honeybee (Apismellifera) venom against Escherichia coli and Staphylococcus aureus.J Asian Nat Prod Res. 2009;11(9):796-804.
117. Galkowska H, Wojewodzka U, Olszewski WL. Low recruitment of immune cells with increased expression of endothelialadhesion molecules in margins of the chronic diabetic foot ulcers.Wound Repair Regen. 2005;13(3):248-254.
118. Olaitan PB, Adeleke OE, Ola IO. Honey: A reservoir for microorganisms and an inhibitory agent for microbes.Afr HealthSci. 2007;7(3):159-165.
119. Gekker G, Hu SX, Spivak M, Lokensgard JR, Peterson PK. Anti-HIV-1 activity of propolis in CD4(+) lymphocyte andmicroglial cell cultures.J Ethnopharmacol. 2005;102(2):158-163.
120. Simuth J, Bilikova K, Kovacova E, Kuzmova Z, Schroder W. Immunochemical approach to detection of adulteration inhoney: physiologically active royal jelly protein stimulating TNF-alpha release is a regular component of honey.J Agric FoodChem. 2004;52(8):2154-2158.
121. Kohno K, Okamoto I, Sano O, Arai N, Iwaki K, Ikeda M, Kurimoto M. Royal jelly inhibits the production ofproinflammatory cytokines by activated macrophages.Biosci Biotechnol Biochem. 2004;68(1):138-145.
122. Jull AB, Walker N, Deshpande S, Honey as a topical treatment for wounds.Cochrane database of systematic reviews(Online). 2013;2.
123. Grembecka M, Szefer P. Evaluation of honeys and bee products quality based on their mineral composition usingmultivariate techniques.Environ Monit Assess. 2013;185(5):4033-4047.
124. Xu X, Gao Y. Isolation and characterization of proteins and lipids from honeybee (Apis mellifera L.) queen larvae androyal jelly.Food Research International. 2013;54(1):330-337.
125. Menniti-Ippolito F, Mazzanti G, Santuccio C, Moro PA, Calapai G, Firenzuoli F, Valeri A, Raschetti R. Surveillance ofsuspected adverse reactions to natural health products in Italy.Pharmacoepidemiol Drug Saf.2008;17(6):626-635.
126. Bankova V. Recent trends and important developments in propolis research.Evid Based Complement Alternat Med.2005;2(1):29-32.
127. Alia O, Laila M, Al D. Antimicrobial effect of melittin isolated from Syrian honeybee (Apismellifera) venom and its woundhealing potential.International Journal of Pharmaceutical Sciences Review and Research. 2013;21(1):318-324.
128. Moghazy AM, Shams ME, Adly OA, Abbas AH, El-Badawy MA, Elsakka DM, Hassan SA, Abdelmohsen WS, Ali OS,Mohamed BA. The clinical and cost effectiveness of bee honey dressing in the treatment of diabetic foot ulcers.Diabetes ResClin Pract. 2010;89(3):276-281.
129. Jan WA, Shah H, Khan M, Fayaz M, Ullah N.Comparison of conventional pyodine dressing with honey dressing for thetreatment of diabetic foot ulcers.Journal of Postgraduate Medical Institute. 2012;Vol.26.
130. Makhdoom A, Khan MS, Lagahari MA, Rahopoto MQ, Tahir SM, Siddiqui KA. Management of diabetic foot by naturalhoney. JAyub Med Coll Abbottabad. 2009;21(1):103-105.
131. Eddy JJ, Gideonsen MD, Mack GP. Practical considerations of using topical honey for neuropathic diabetic foot ulcers:A review.WMJ. 2008;107(4):187-190.
132. Kamaratos AV, Tzirogiannis KN, Iraklianou SA, Panoutsopoulos GI, Kanellos IE, Melidonis AI. Manuka honey-impregnated dressings in the treatment of neuropathic diabetic foot ulcers.Int Wound J. 2012.
133. Hossein Khadem H, Yaghob K, AkbarAli A. Treatment of Diabetic Foot Ulcer with Propolis and Olive Oil: A CaseReport.Knowledge & Health Journal. 2012;6(4):35-38.
134. Siavash M, Shokri S, Haghighi S, Mohammadi M, Shahtalebi MA, Farajzadehgan Z. The efficacy of topical Royal Jellyon diabetic foot ulcers healing: A case series.J Res Med Sci. 2011;16(7):904-909.
135. Siavash M, Shokri S, Haghighi S, Shahtalebi MA, Farajzadehgan Z. The efficacy of topical royal jelly on healing ofdiabetic foot ulcers: a double-blind placebo-controlled clinical trial.Int Wound J. 2013;8(10):12063.
136. Shukrimi A, Sulaiman AR, Halim AY, Azril A. A comparative study between honey and povidone iodine as dressingsolution for Wagner type II diabetic foot ulcers.Med J Malaysia. 2008;63(1):44-46.
11/18/2017 What’s the buzz: bee products and their potential value in diabetic wound healing. « Journal of Diabetic Foot Complications
